CT Coronary Angiogram Report
Patient Name: John Smith
Gender: Male
Date Of Birth: 15/03/1968
NHS Number: 123 456 7890
Ref. Consultant: Dr. Alice Brown
Date Of Scan: 28/10/2024
Date Of Report: 01/11/2024
KV: 120 kV
MA: 350 mA
Dose: 4.5 mSv
Indications: Atypical chest pain, suspected coronary artery disease.
Drugs: Glyceryl Trinitrate (GTN) 0.4mg sublingual, Metoprolol 5mg IV.
HR: 62 bpm, sinus rhythm.
Technique: Prospectively ECG-gated axial acquisition, 64-slice CT scanner, 0.625 mm slice thickness, contrast administration with bolus tracking.
Quality: Excellent image quality, minimal motion artefact, good contrast opacification.
Calcium Score: 180 Agatston units (LMS: 0, LAD: 110, LCx: 30, RCA: 40).
Cor. Origin: Normal origins and courses of proximal coronary arteries.
LMS: Normal.
LAD: Moderate calcified plaque in the proximal segment with 40% stenosis. Distal LAD appears patent.
LCx: Non-calcified plaque in the mid-segment causing mild (20%) stenosis.
RCA: Non-calcified plaque in the proximal segment with 30% stenosis. Distal RCA appears patent.
Others: Normal great vessels connections. Normal SVC, IVC, and pulmonary veins drainage.
Conclusion:
1. Calcium score of 180 Agatston units, indicating moderate atherosclerotic burden.
2. Moderate calcified plaque and 40% stenosis in the proximal Left Anterior Descending artery.
3. Mild non-calcified plaque and 20% stenosis in the mid Left Circumflex artery.
4. Mild non-calcified plaque and 30% stenosis in the proximal Right Coronary Artery.
CT Coronary Angiogram Report
Patient Name: [Patient's full name] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this field entirely. Write on the same line.)
Gender: [Patient's gender] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this field entirely. Write on the same line.)
Date Of Birth: [Patient's date of birth] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this field entirely. Write on the same line.)
NHS Number: [Patient's NHS number] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this field entirely. Format as xxx xxx xxxx. Write on the same line.)
Ref. Consultant: [Referring consultant's full name] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Date Of Scan: [Date the scan was performed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Date Of Report: [Date the report was generated] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
KV: [Kilovoltage setting used during the scan] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
MA: [Milliamperage setting used during the scan] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
Dose: [Radiation dose recorded for the scan] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
Indications: [The clinical indication for the CT coronary angiogram] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)
Drugs: [Premedication details including GTN and any intravenous medications with dosages] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading. Use a capital first letter for each medication name.)
HR: [Heart rate and rhythm recorded during the scan] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)
Technique: [Scanning technique used including scan mode and sequences performed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)
Quality: [Assessment of image quality] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Calcium Score: [Total calcium score in Agatston units with breakdown by vessel including LMS, LAD, LCx, and RCA] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely.)
Cor. Origin: [Coronary artery origins and proximal courses] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading. If the clinician explicitly states the coronary artery origins and courses are normal, write "Normal origins and courses of proximal coronary arteries.")
LMS: [Left main stem findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading. If the clinician explicitly states the left main stem is normal, write "Normal.")
LAD: [Left anterior descending artery findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading. If the clinician explicitly states the left anterior descending artery is normal, write "Normal.")
LCx: [Left circumflex artery findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading. If the clinician explicitly states the left circumflex artery is normal, write "Normal.")
RCA: [Right coronary artery findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading. If the clinician explicitly states the right coronary artery is normal, write "Normal.")
Others: [Other cardiac and vascular findings including great vessel connections, SVC, IVC, and pulmonary vein drainage] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading. If the clinician explicitly states these findings are normal, write "Normal great vessels connections. Normal SVC, IVC, and pulmonary veins drainage.")
Conclusion: [A numbered summary of the key findings including calcium score interpretation and coronary artery assessment] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this section entirely. Never invent or infer a diagnosis. Present each conclusion point as a separately numbered item.)
